Provider Demographics
NPI:1679070437
Name:MALLORY & WHITE PC
Entity Type:Organization
Organization Name:MALLORY & WHITE PC
Other - Org Name:WILLAMETTE FALLS NEUROPSYCHOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:LOREN
Authorized Official - Middle Name:
Authorized Official - Last Name:MALLORY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, ABPP
Authorized Official - Phone:503-303-4257
Mailing Address - Street 1:619 MADISON ST STE 108
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-2354
Mailing Address - Country:US
Mailing Address - Phone:503-303-4257
Mailing Address - Fax:
Practice Address - Street 1:619 MADISON ST STE 108
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-2354
Practice Address - Country:US
Practice Address - Phone:503-303-4257
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-09
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR978261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center